Pulmonary vein isolation with or without empirical cavotricuspid isthmus ablation

Background Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with significant morbidity. Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for AF, while cavotricuspid isthmus (CTI) ablation is primarily indicated for typical atrial flutter. Given the potential interplay between AF and flutter, some operators empirically add CTI ablation (eCTI) during PVI procedures, although its value in the absence of documented flutter remains uncertain. Objective This study aimed to evaluate the efficacy and safety of PVI-only versus PVI + eCTI ablation in patients with atrial fibrillation, with the hypothesis that empirical CTI ablation may improve long-term outcomes, particularly in persistent AF. Methods We conducted a single-center, retrospective cohort study including 422 patients undergoing first-time radiofrequency ablation for AF at a tertiary referral center between 2020–2022. Patients were divided into PVI-only (n=244) and PVI + eCTI (n=178) groups. Procedures were performed with Radiofrequency energy, guided by the CARTO 3D mapping system. The primary endpoint was freedom from atrial arrhythmia at 12 months after a 60-day blanking period, confirmed via ECG, Holter, or event recorder. Procedural characteristics, safety outcomes, and predictors of recurrence were also analyzed. Results Baseline demographics were balanced between groups, though patients in the PVI-only group had more severe atrial dilatation (p<0.001). Procedure duration was significantly shorter in the PVI-only cohort (median 80 min [65–90]) compared to PVI + eCTI (99.5 min [80–118]; p<0.001). At 12 months, arrhythmia-free survival was 79% in the PVI-only group and 84% in the PVI + eCTI group (p=0.24). Subgroup analyses for paroxysmal (86% vs 90%, p=0.34) and persistent AF (69% vs 74%, p=0.57) revealed no significant differences. Multivariate Cox regression confirmed that eCTI ablation had no independent effect on recurrence (HR 0.93, 95% CI 0.57–1.53; p=0.78). Key predictors of recurrence included persistent AF and moderate-to-severe atrial dilatation. Typical atrial flutter recurrence after PVI-only was rare, calculated at 1.1%. Conclusion Despite its theoretical rationale, empirical CTI ablation did not improve arrhythmia-free survival when added to PVI. PVI-only ablation offered shorter procedure times without compromising efficacy or safety. Importantly, the very low incidence of subsequent typical flutter in the PVI-only group suggests that routine prophylactic CTI ablation is not justified, given the procedural cost and potential incremental risk. These findings are consistent with prior studies, reinforcing a tailored ablation strategy focused on documented flutter or patient-specific substrates (1). Future multicenter prospective trials with longer follow-up are needed to clarify the role of CTI ablation in AF management.